New Client Registration Form

New Client Registration Form

In order to make the most of your first appointment, please can you complete the following information. This information is confidential.
Full Name*

First NameLast Name
Residential Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Birth Date

DayMonthYear
What is your gender identity?
Phone Number*

Country CodePhone Number
Email*
example@example.com
Occupation*
Company
Relationship status*
Do you have children? If so, how many?*
How did you find me?*
Emergency contact / Next of kin*

Full name

Street Address Line 2

Relationship to youContant number

Postal / Zip Code
GP Details*

GP Name

Street Address Line 2

GP Surgery NameContant number

Postal / Zip Code
Method of funding*
Insurance Provider (if applicable)
Have you had previous psychological care or counselling? If yes, please give the name of the clinician(s), the months you saw them (e.g., Nov 06-Feb 07), and the nature of the difficulty at the time*
Have you ever been hospitalised for a psychological difficulty? If yes, please give the dates and the nature of the difficulty at the time*
Please describe any significant current or past medical problems*
Please list all medications you currently take. Include prescription and over-the-counter medications and the dosage of each*
In your own words, what is the nature of the concern that you wish to address in therapy? Feel free to describe this in as much or as little detail as you wish*
By submitting this form you are accepting the terms and conditions as set out in the Informed Consent Form
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